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Practice-based commissioning: the situation to date

1 December 2006

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Richard More
General Practitioner
Primary Care Consultancy Director

Richard has been a GP principal in South Somerset since 1991. Since 2004, he has been fortunate enough to travel around England, meeting new people and helping develop PbC clusters. Richard remains convinced that you can’t beat homegrown Somerset cider

It’s coming up for two years since the Department of Health published Practice-based commissioning: promoting clinical engagement, which makes it a good moment to stop and appraise what has happened with PbC – or perhaps what hasn’t happened, since there are few examples of improved patient services as a consequence of the initiative.

The paper itself was frustratingly short of detailed guidance for many practices, who were looking for a clear steer as to what to actually do, but it did at least leave the primary care trusts (PCTs) in little doubt, through the emphasis on national and local targets in paragraph 22, that what was not happening here was a return to the old fundholding scheme.

Instead, what those PbC enthusiasts out there were tasked to achieve was a business plan. One that was researched and cost-effective. One that, if it involved a change of provider, contained costed service provision contracts and could demonstrate the thoroughness, probity and effectiveness of the new organisations being created to deliver the plan.

PbC not as easy as ABC
So, not only creating a business plan, then, but also creating new organisations – something that even the corporate world regard as resource-hungry, business-critical and time-consuming processes. The practices were clearly expected to do this using their own time and resources, since the process requires them to have a plan agreed before any funding would follow.

Unsurprisingly, this investment in the relatively unknown structures and systems of the commercial world required a huge leap of faith from its enthusiasts. As a result, practices have split between those that are “up for” the ride and those that aren’t. Equally unsurprisingly, those in the “wait and see” camp have so far formed the majority.

This could make the current environment look very gloomy. The heart of PbC lies in the axiomatic idea that the experts in the business of the business of the health service – that is, the prevention and treatment of illness – should be leaping forward to guide the organisation to the most effective and efficient way of doing things. This means that the taxpayer’s hunger for value needs to be satisfied through PbC delivering reduced spend on the big-ticket items, such as drug prescriptions and hospital admissions.

These items have price tags high enough to make the debate about GP salaries a side issue. These are also the precise concerns that those in general practice with vision have been eyeing for years, rather like the way a fox looks at a rabbit. Although the challenges of PbC are huge, it seems a shame to pass up the chance to eradicate all that waste after all these years of asking for the opportunity.

Of course, the thing that tipped those practices more akin to sheep than foxes into looking again at PbC is the prospect of even greater risk in inertia. Ours is no longer a world where all general medical services are delivered by partnerships of practitioners regulated by a single national contract.

Threat of new providers
Some practices are more efficient than others; some larger practices have vision, hunger and the organisational capacity for the future; some commercial enterprises with a track record of efficiency in other markets might like to play in this one. The trend to buy services from new providers is on the increase. The argument goes that if we don’t engage in PbC, someone else might. The loss of control, and potentially of income, that this might entail is sufficient to prompt a reappraisal of the risks of investment for some. The words “rock” and “hard place” spring to mind.

This tension has resulted in a typical health service fudge, where some embark on a course of action with a sufficient lack of enthusiasm to ensure that no outcome is ever going to emerge.

An opportunity not to be wasted
Plans have been written that absorb paper and ink but offer little change and deliver less. PCTs, anxious over their own futures, have sometimes been inclined to accept the process rather than focus on the outcome.

Groups of GPs have been made by their practice managers to look into the abyss of incorporation, and have baulked at the responsibilities and accountabilities this entails. They have then drifted instead into the familiarity of their old club structures, where accountability is blurred and personal responsibility easy to avoid. This is the “Sir Humphrey” approach, so typical of our world and so responsible for the frustrations that many of us feel.

“Do what you’ve always done and get what you’ve always got” really isn’t a sufficient approach. It will be a tragic waste of our time and (therefore) taxpayers’ pounds if PbC is going to be another opportunity lost for general practice. Of course, incorporation and business planning are scary and risky, but professional management does exist in practices and best-practice solutions are out there for those that care to look.

By investing in, and trusting, good management, clinicians can achieve a way forward that eases so many of their daily irritations at the system they work within. We do have ways of sending fewer people to hospital and spending less on drugs and treatment.

The prize
By applying our energy and efforts to making a change, rather than frustrating one, the prize – delivering better outcomes for patients closer to their homes at an affordable cost, which incorporates the correct balance between prevention and treatment – is up for grabs. Surely that is what we all aim to do when we get up in the morning?